Pilot Debrief

BEECH A36 near Hooksett, NH — 2012-10-25

Final reportERA13FA039
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Date
2012-10-25
Location
Hooksett, NH, USA
Aircraft
BEECH A36
Registration
N4325W
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Cruise

Probable cause

The pilot's total incapacitation in flight due to an acute heart attack.

NTSB narrative

The airplane was on the second leg of a visual flight rules cross-country flight and was receiving flight following services from air traffic control (ATC). About 10 minutes after establishing radio and radar contact with ATC, the airplane's discrete transponder code was lost, and an air traffic controller made several unsuccessful attempts to contact the airplane. Postaccident review of radar data showed a primary target, correlated to be the accident airplane, as it tracked north toward the pilot's destination. About 7 minutes later, the target initiated a left turn south, paralleling its northerly course. The last several radar returns showed the target tracking southbound directly over an interstate highway. The last radar return was located about 2,500 feet north of where the airplane was found resting upright against an interstate guardrail. Postaccident examination of the airframe and engine revealed no evidence of any mechanical malfunctions or anomalies that would have precluded normal operation. Review of the pilot's medical history revealed multiple medical conditions and a coronary artery bypass graft procedure for three-vessel coronary artery disease and insertion of a pacemaker for symptomatic bradycardia. The pilot provided the Federal Aviation Administration (FAA) extensive documentation regarding his conditions and the medications used to treat the conditions and was granted special-issuance medical certificates. His most recent medical certificate was issued 3 months before the accident. The pilot's autopsy report indicated that he died from an acute heart attack at some point during the accident flight. The pilot-rated passenger held a pilot certificate, and, according to the pilot's logbook, had acted as a safety pilot on flights in the accident airplane during the previous year. However, she did not hold a current medical certificate, and no other evidence of recent flight experience could be found to suggest that she was capable of flying the accident airplane unassisted.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen to land or divert after losing transponder contact.

NTSB coding

Evidence available

  • ATC audio
  • FDR / data
  • ADS-B / radar
  • Photos
  • 17 docket documents
View NTSB final reportView NTSB docket

Docket documents17

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